Application for Hardship Waiver - California
State of California¡ªHealth and Human Services Agency
Department of Health Care Services
Application for Hardship Waiver
Submission of this application is necessary to apply for a waiver of the claim due to substantial
hardship. Only the applicant's proportionate share of the claim can be waived. An applicant has
60 days from the date stated on the Department of Health Care Services¡¯ (Department) notice of
claim in which to submit an application. All of the information requested in the application is
voluntary; however, failure to completely and accurately provide the information may result in a
denial of the waiver application.
A substantial hardship shall not exist when the decedent or applicant created the hardship by
using estate planning methods to divert or shelter assets in order to avoid estate recovery.
A. ESTATE OF:
Case Number:
Total Value of Estate:
Claim Amount:
A. ESTATE OF:
Total Value of Estate:
Case Number:
Date of Application:
Date of Application:
Claim Amount:
Your Share of Estate: (50%, 75%, 100% etc). Attach a copy of the Will or Trust
Your Share of Estate: (50%, 75%, 100% etc). Attach a copy of the Will or Trust
Your Share of Estate: (50%, 75%, 100% etc).
Attach a copy of the Will or Trust
==================================================================================================
Middle,Middle,
Last): Last): Social
Social
Security
Driver's
License/ID
Birth
Date
(m/d/y):
Social
Security
Number: Number:
License/ID
Number: Number:
Date
(m/d/y):
B. APPLICANT¡¯S NAME (First,
Security
Number: Driver's
Driver's
License/ID
Number: Birth
Birth
Date
(m/d/y):
Social Security
Driver's License/ID Number:
Birth Date
B.APPLICANT¡¯S
APPLICANT¡¯S
NAME
B.
NAME (First,
Middle,(First,
Last):
Number:
(m/d/y):
Relationship
to decedent:
Relationship
to decedent:
Street
Address:
Street
Address:
Street
Address:
City:
City:
City:
State:
State:
State:
Telephone
Number:Number:
Telephone
Number:
Telephone
Zip:
Zip:
Zip:
(
P. O. Box
City:
P. O. Box
P.O. Box
State:
City:
City:
Spouse's Name (First, Middle, Last):
Applicant¡¯s Employer:
Applicant¡¯s Employer:
Applicant's
Zip:
Zip:
State:
State:
Zip:
Social Security Number:
Spouse's Name (First, Middle, Last):
Spouse's Name (First, Middle, Last):
Social Security Number:
Social Security Number:
DateDate
(m/d/y):(m/d/y):
Driver's License/ID Number: Birth
Birth
Birth Date (m/d/y):
Driver's License/ID Number:
Driver's License/ID Number:
Address:
Address:
City/State/Zip:
City/State/Zip
City/State/Zip
Telephone Number:
Telephone Number
Address:
Address:
Address:
City/State/Zip
City/State/Zip:
City/State/Zip
Telephone Number:
Telephone
Address:
Telephone Number
(
)
Employer:
Spouse's
Employer:
Spouse's
Employer:
Spouse's
Employer:
)
Telephone Number:
(
)
Number:
Yes
Are there any unmarried children, or any other persons, living with the applicant?Yes
Yes (
Are there any unmarried children, or any other persons, living with the applicant?
Are there any unmarried children, or any other persons, living with the applicant?
Yes
No
) No
No
(
No
)
Ifyes,
yes,
listname,
their
name,
birth
date,
and
relationship
to applicant.
If
name,
birth
date,
and
relationship
to applicant.
If yes,
list list
their their
birth
date, and
relationship
to applicant.
Please
include
anyorrent
or household
contributions
made to
the applicant
Please
include
any rent
household
contributions
made to the applicant
Section
E.
Please include any rent or household contributions made
to the
Section
E. applicant Section E.
Name
(First,
Middle, Last):
Last):
Name
Middle,
Name
(First,(First,
Middle,
Last):
Birth Date (m/d/y):
Name
(First,
Middle,
Name
(First,
Middle,
Last):
Name
(First,
Middle,
Last):
Birth
(m/d/y):
BirthDate
Date
(m/d/y):
Last):
Name
(First,
Last):
Name
(First,
Middle,
Last):
Name
(First,
Middle,Middle,
Last):
DHCS 6195 (8-07)
Birth Date
Date (m/d/y):
Birth
(m/d/y):
Relationship
to applicant:
applicant:
Relationship
to
Relationship
to applicant:
Birth Date (m/d/y):
Relationship
to applicant:
Relationship
to applicant:
Relationship to applicant:
Birth
Date
(m/d/y):
Birth
Date
(m/d/y):
Birth
Date
(m/d/y):
Relationship
to to
applicant:
Relationship
applicant:
Relationship
to applicant:
1
State of California¡ªHealth and Human Services Agency
Department of Health Care Services
C. Criteria for Hardship Waiver consideration can be found in the California Code of Regulations, Section 50963.
Please check the criteria below that qualifies the applicant for a hardship waiver. Attach documentation that
provides substantiation for the criteria selected. Failure to provide sufficient substantiation may result in a
denial of the waiver.
(
) Receiving the inheritance from the estate will enable the applicant to discontinue eligibility for public assistance
payments and/or medical assistance programs.
(
) The estate property is part of an income-producing business, including a working farm or ranch, and recovery of
medical assistance expenditures would result in the applicant losing his or her primary source of income.
(
) The applicant is aged, blind, or disabled and has continuously lived in the decedent's home for at least one year prior to
the decedent¡¯s death and continues to reside there, and is unable to obtain financing to repay the State. The applicant
shall apply to obtain financing, for an amount not to exceed his or her proportionate share of the claim, from a financial
institution as defined in Probate Code Section 40. The applicant shall provide the Department with a denial letter(s)
from the financial institution.
(
) The applicant provided care to the decedent for two or more years that prevented or delayed the decedent¡¯s admission
to a medical or long-term care institution. The applicant must have resided in the decedent¡¯s home during the period
care was provided and continue to reside in the decedent¡¯s home. The applicant must provide written medical
substantiation from a licensed health care provider(s), which clearly indicates that the level and duration of care
provided prevented or delayed the decedent from being placed in a medical or long-term care institution.
(
) The applicant transferred the property to the decedent for no consideration.
(
) The equity in the real property is needed by the applicant to make the property habitable, or to acquire the necessities of
life, such as food, clothing, shelter or medical care.
D. DECEDENT¡¯S ESTATE CONSISTS OF: Check all applicable assets and complete all related information.
List all estate assets including property conveyed through joint tenancy, tenancy in common, life estate, living,
trust, annuities purchased on or after September 1, 2004, life insurance policy, or retirement account. Please
attach copies of recorded deed(s), registration(s), bank statement(s), listing agreements/contracts, life insurance
policy statements, stocks, bonds, and annuity documentation, etc.
Market
Market Value
$
Market Value $
Market Value $
Value $
(
) Real
Real
Property
Property
Real
Property
____________
(
Mobile
Home
Mobile
Home
) Mobile Home
____________
Is the
Is the property listed for
sale? Yes
YesYes (
) NoNoNo (
)
Yes
property
If
no,
If no, Please explain.
listed for
Please
_______________________________________________
Mortgage Owed $
Mortgage Owed $
Mortgage Owed
Is the property listed for sale?
Is the property listed for sale?
If no, please explain.
If no, Please explain.
$
______________
sale?
explain.
______________
Estate Property Street Address:
Estate Property Street
City:
City:
Estate Property Street Address:
State:
State:
City:
State:
Zip:
Zip:
Zip:
Address:
Is anyone living in the property?
Is anyone living in the property?
Yes
Yes
Yes
Is anyone living in the property?
Yes (
) No
No (
No
No
)
Amountofofmonthly
monthly
rentcollected?
collected?
Is the property being rented? Amount
monthly
rent
collected?
Amount
ofofmonthly
rent
collected?
Amount
rent
Is the property being rented?
Is the property being rented?
If yes, how long have they lived in the property?
If yes, how long have they lived in the property?
If yes, how long have they lived in the property?
___________________________________________
Name
and relationship
to decedent (if any) to decedent (if any).
Name
and relationship
Name and relationship to decedent (if
any).
Are
paying
spacespace
rent for the
mobile
home?
Areyouyou
paying
rent
for the
mobile
home?
Are you paying space rent for the mobile home?
Yes
Yes
Yes (
) No
No (
No
)
If
If yes,
yes, how
how much?
much? (Attach
(Attach statement)
statement)
the estate
estate property
property held
IsIs the
heldininaatrust?
trust?
Yes
Yes
No
) No
No (
)
Type
of of
trust?
(Attach
copy
of Trust
document)
Type
(Attach
copy
of Trust
document)
Type
oftrust?
trust?
(Attach
copy
of Trust
document)
Yes (
Is
Is this
this estate
estate property
property part
part of
of an
an income
income producing
producing business,
business, including
including a
a working
working farm
farm or
or ranch?
ranch?
If yes, how much? (Attach statement)
Yes
Is this estate property part of an income producing business, including a working farm or ranch? Yes
(
Yes
(
)
No
(
)
Yes
Yes
No
Yes
No
(PleaseSection
include
income in Section E.)
income
E.)
(Pleasein include
income in Section E.)
Name
Address
of Bankof Bank
Name
&
Address
of
( ) Bank
Bank
Account Checking
$
Savings
$
Name
& Address
Savings
$$
Savings
Name
&&
Address
of Bank
Bank
Bank
BankAccount
Account
Checking
Checking $
$
Savings
$
)
No
No
No (
)
If
isisthis
your
primary
source
of source
income?
(Please
include
yes,
isthis
this
your
primary
of income?
IfIfyes,
yes,
your
primary
source
of income?
Account
Number
Account
Number
Account
Number
Account Number
Account
(
) Annuities
Annuities
Annuities
(
Life
Estate
) Life
Life
Estate
Estate
DHCS 6195 (8-07)
Value $
Value
Value $$
Value $
Value $
Value $
Value $
Type
Date Purchased
Type
Type
Type
Date
Purchased
Date
Date
Purchased
Purchased
Type
Type
Type
Type
2
State of California¡ªHealth and Human Services Agency
(
Life
LifeInsurance
InsurancePolicy
Policy
) Life Insurance Policy
Value $
Value $
Beneficiary(s)
Beneficiary(s)
Value $
Value $
Beneficiary(s)
Beneficiary(s)
Beneficiary(s)
Type
Value $
Value $
Type
Type
Date Purchased
Date Purchased
Value $
Retirement
Accounts
( ) Retirement
Retirement
Accounts
Retirement
Accounts
(IRA/Other)
Accounts
IRA/Other)
(IRA/Other)
(
Department of Health Care Services
Beneficiary(s)
Value $
Stocks/Bonds/Notes/Other
) Stocks/Bonds/Notes/Other
Stocks/Bonds/Notes/Other
Stocks/Bonds/Notes/Other
Value $
Type
Type
(CDs/IRA/ROTH/IRA/Other)
(CDs/IRA/ROTH
(CDs/IRA/ROTH)
Date Purchased
APPLICANT¡¯S
MONTHLY
INCOME.
Please
attach
copy
most
recent
federal
state
income
return
E.E.
APPLICANT¡¯S
MONTHLY
INCOME. Please
attach copy
of most
recent
federal
and
state
income
tax federal
return
E.
APPLICANT¡¯S
MONTHLY
INCOME.
Please
attach
copy
of of
most
recent
andand
state
income
tax tax
return
Applicant¡¯sNet
NetPay
Pay(Attach
(Attachtwo
two months
months most
Applicant¡¯s
most recent
recentpay
paystubs)
stubs)
$______________________
(If not monthly, please indicate weekly, bi-weekly, etc.)
(If not monthly, please indicate weekly, bi-weekly, etc.)
Spouse¡¯s
NetNet
Pay
(Attach
two
months
mostmonths
recent
paymost
stubs)recent
(If
notstubs)
Monthly,
please
Spouse¡¯s
Net
Pay
(Attach
pay (If
stubs)
Spouse¡¯s
Pay
(Attach
two two
months
most
recent
pay
not indicate
$______________________
(If not
monthly,
weekly,
bi-weekly,
etc.)please indicate weekly, bi-weekly, etc.)
monthly,
please
indicate weekly, bi-weekly, etc.)
Rents
Paid
to Applicant
Applicant
(Please
provide
rental
Rents
Paid
to Applicant
(Please
provide
rental agreement)
Rents
Paid
to
(Please
provide
rentalagreement)
agreement)
Social
Security/Retirement/Pensions/Annuities
(Attach
two most
recent
Social
Security/Retirement/Pensions/Annuities
(Attach two
most (Attach
recent
stubs)
Social
Security/Retirement/Pensions/Annuities
two
moststubs)
recent
$______________________
stubs)
$______________________
Business
& Loss
Lossstatement)
statement)
BusinessIncome
Income (Attach
(Attach Profit
Profit &
$______________________
Disability
(Attach
award
letter)
Disability
(Attach
award
letter)
$______________________
Public Assistance
Assistance (Attach
Public
(Attachaward
awardletter)
letter)
$______________________
Other
Other
income
income(source):
(source): Dividends,
Other
income
Other income (source):____________________________
$______________________
interest, child
support,interest,
alimony,child
tips,
(source):
Dividends,
commissions,
etc.tips,
(Attach
support,
alimony,
Dividends, interest, child support, alimony, tips, commissions, etc.
(Attach documentation supporting other income)
documentation
supporting
commissions,
etc.
(Attach other
income)
documentation
supporting other
income)
TOTAL INCOME
INCOME
TOTAL
$______________________
F.F.APPLICANT'S
MONTHLY
EXPENSE. If EXPENSE.
monthly expenses exceed monthly income, an explanation must be provided (please attach separately):
APPLICANT'S
MONTHLY
If monthly expenses exceed monthly income, an explanation must be provided (please attach separately):
Mortgage/Rent (Attach copy of annual mortgage statement/rent agreement/receipts)
$______________________
Alimony/Child Support
Paid to:
(Please provide documentation of 3 months of payments)
$______________________
Name:
Name:
Name: __________________________________________________________
Address:
Address:
Address: _________________________________________________________
Telephone: _______________________________________________________
Telephone:
Telephone:
Telephone:
Groceries
Groceries
Groceries
$______________________
Utilities(Attach
(Attach
documentation
of 3 months
Utilities
documentation
of 3 months
of bills)of bills)
$______________________
Medical
(Attach
copy ofcopy
outstanding
bills not paid by
insurance)
Medical
(Attach
of outstanding
bills
not paid
$______________________
by insurance)
Insurance (Attach copy of statement for auto, health, life, homeowners, etc.)
$______________________
Auto Expenses (Include car payments, gas, maintenance receipts)
$______________________
Installment Payments (Attach copy of statements)
$______________________
Other
(Explain) (Attach
(Attach
Other Expenses
Expense (Explain)
Other Expenses (Explain) (Attach
documentation
documentation supporting
supporting other
other
documentation supporting other
expenses)
expenses)
expenses)
Other Expenses (Explain) ____________________________
(Attach documentation supporting other expenses)
TOTAL
MONTHLY
EXPENSES EXPENSES
TOTAL
MONTHLY
TOTAL
MONTHLY
EXPENSES
TOTAL MONTHLY EXPENSES
DHCS 6195 (8-07)
3
$______________________
$______________________
State of California¡ªHealth and Human Services Agency
Department of Health Care Services
G. APPLICANT'S ASSETS AND DEBTS
REAL ESTATE (Include personal residence, vacation property, etc. Please attach copy of annual mortgage statement. If
monthly payment is made, it should be accounted for in Section F.)
Address
city/county/state/zip):
Mortgage
Current
Value:
Mortgage
Balance:
Address
(include(include
city/county/state/zip):
Mortgage
Holder: Holder:
Current
MarketMarket
Value:
Mortgage
Balance:
Address (include
Mortgage Holder:
Current Market Value:
Mortgage Balance:
city/county/state/zip):
BANK
BANK ACCOUNTS
ACCOUNTS (Including
(Including Savings
Savings && Loans,
Loans, Credit
Credit Unions,
Unions, Certificates
Certificates of
of Deposit,
Deposit, Individual
Individual Retirement
Retirement Accounts.)
Accounts.)
BANK ACCOUNTS (Including Savings & Loans, Credit Unions, Certificates of Deposit, Individual Retirement Accounts.)
Account Number:
Number:
Account
Name of Institution & Address:
Account Number:
Name
Name of
of Institution
Institution && Address:
Address:
Type of Account (checking, savings, etc):
etc.):
Type of Account (checking, savings, etc):
Balance:
Balance:
Balance:
LIFE INSURANCE & ANNUITIES (Monthly payments should be listed in Section E if income, and/or Section F if expense)
LIFEINSURANCE
INSURANCE
& ANNUITIES
(Monthly
payments
listed inESection
E and/or
if income,
and/or
Section F if expense.)
LIFE
& ANNUITIES
(Monthly
payments
should should
be listedbe
in Section
if income,
Section
F if expense.)
Name
of Company:
Name
of Company:
Policy
Number:
Policy
Number:
Name of Company:
Policy Number:
CREDIT
CARDS
payments
CREDIT
CARDS
(Monthly (Monthly
payments should
be listed in should
Section F.)be
CREDIT CARDS (Monthly payments should
be in
listed
in Section
F.)
listed
Section
F.)
Name of Credit Card, Bank, etc.:
Total Amount Owed:
Name
Nameof
ofCredit
CreditCard,
Card,Bank,
Bank,etc.:
etc.:
Total Amount Owed:
Total Amount Owed:
MOTOR
VEHICLES
all cars,
trucks,
motorcycles,
boats,
recreational
vehicles
- Paid
forbeor
not.
Monthly
MOTOR
VEHICLES
(Include (Include
all cars, trucks,
motorcycles,
boats,
recreational vehicles
- Paid
for or not. Monthly
payments
should
listed
in Section
F.) payments
MOTOR VEHICLES (Include all cars, trucks, motorcycles, boats, recreational vehicles - Paid for or not. Monthly payments should be listed in Section F.)
should be listed in Section F.)
Year, Make, and License Number:
Year,
Year, Make,
Make, and
and License
License Number:
Number:
Date Purchased:
Current Value:
Date Purchased:
Date Purchased:
Current Value:
Current Value:
Loan Balance:
Loan Balance:
Loan Balance:
OTHER ASSETS (Miscellaneous items you own or are currently buying, e.g., stocks, bonds, etc.)
OTHER ASSETS (Miscellaneous items you own or are currently buying, e.g., stocks, bonds, etc.)
OTHER ASSETS (Miscellaneous items you own or are currently buying, e.g., stocks, bonds,
etc.)
Description:
Description:
Description:
DHCS 6195 (8-07)
Date Purchased:
Current Value:
Date Purchased:
Date Purchased:
Current Value:
Current Value:
4
Loan Balance:
Loan Balance:
Loan Balance:
State of California¡ªHealth and Human Services Agency
Department of Health Care Services
H. ATTACHMENTS/DOCUMENTATION/CERTIFICATION
All of the information requested in the application is voluntary; however, failure to completely
and accurately provide the information may result in a denial of the waiver application. Any
errors or omissions in the information provided by the applicant, that would affect the
Department's decision, may be a basis for denial of the request for hardship waiver. If
applicable, attach a copy of:
1. The most recent real estate sales contract or listing agreement.
2. The deed(s), registration(s), order determining succession, Affidavit of Death of Joint
Tenant, life estate or trust documents.
3. Applicant¡¯s most recent annual mortgage statement and/or rental agreement/receipts.
4. A current appraisal of estate property (including name of appraiser and license number).
5. The Will, Trust, or other court documents showing the names of all the heirs and the
percentage of the estate each will receive.
6. A certified estimate by a licensed contractor for any work that is necessary to make the
property habitable or marketable.
7. Applicant¡¯s most recent federal and state income tax returns.
8. Payroll stubs or other proof of monthly-earned income.
9. The most recent Profit & Loss Statement from business(s).
10. Documentation/receipts of any bills you paid on behalf of the decedent after their death.
11. The decedent's bank statement at the time of death.
12. Applicant¡¯s bills/statements substantiating medical bills, insurance bills, installment
payments.
13. Documentation/substantiation for meeting the hardship criteria. (Section C.)
14. Statements verifying expenses such as burial expenses, out-of-pocket administration
expenses (taxes, insurance, maintenance, etc.).
15. Copies of annuity, life insurance, and/or pension documents.
16. Written medical substantiation from a licensed health care provider(s), which clearly
indicates that the level and duration of care provided prevented or delayed the decedent
from being placed in a medical or long-term care institution.
17. Documentation or evidence that the applicant who provided care to the decedent resided
in the decedent¡¯s home during the period care was provided and continues to reside in
the decedent¡¯s home.
18. A denial letter(s) from the financial institution.
Certification
I understand that the statements I have made on this application are subject to investigation
and verification. I declare under penalty of perjury, that the statements I have given on this
form, to the best of my knowledge, are true and correct.
Signature of Applicant (Person applying for Waiver)
Signature of Applicant (Person applying for Waiver)
Signature of Applicant (Person applying for Waiver)
Print or Type Full Name
Print or Type Full Name
Print or Type Full Name
Telephone Number
Telephone Number
Telephone Number
(
DHCS 6195 (8-07)
5
Date
)
Signature
ofof
Person
Completing
(If different
from above)
Number
Signature
Person
Completing
Form
(If different
from above)
orName
Type
Name Telephone
Telephone
Number
Print
or Full
Type
FullFull
Name
Signature
of Person
Completing
Form
(if differentForm
from above)
Print
orPrint
Type
Telephone
Number
(
Date
Date
)
Date
Date
Date
................
................
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